Section 7 AAC 120.210 - Service authorization(a) A provider seeking service authorization must make a request electronically or in writing on a certificate of medical necessity.(b) Service authorization is required for (1) the rental of durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2) that is indicated as requiring service authorization in the Alaska Medicaid DMEPOS Fee Schedule, Tables 1-5 through 1-9, adopted by reference in 7 AAC 160.900;(2) medical supplies that exceed the maximum units or a 30-day limit set by the department;(3) customized or optimally configured durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2);(4) items that are listed as requiring service authorization on the Alaska Medicaid DMEPOS Fee Schedule, Tables 1-5 through 1-9, adopted by reference in 7 AAC 160.900 or the Alaska Medicaid DMEPOS Interim Fee Schedule;(5) items that are identified as miscellaneous in the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900;(6) respiratory therapy assessment visits for ventilator-dependent recipients; (7) home infusion therapy;(8) enteral and oral nutritional products;(9) the purchase of durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2) for a recipient in a skilled nursing facility or intermediate care facility;(10) continuous oxygen for a recipient in a skilled nursing facility or an intermediate care facility;(11) the purchase of durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2) if the charge to the department exceeds $1,000;(12) medical supplies and services for a single claim or for a 30-day supply if the charge to the department exceeds $1,000;(13) durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2) requiring CMS prior authorization under 42 C.F.R. 414.234(c)(1);(14) Medicare-covered durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2) that are for a recipient who is eligible under both Medicare and Medicaid, and that Medicare (A) has determined medically unnecessary for that recipient; or(B) has denied after finding that a provider sought payment in excess of copay and deductible;(15) optimally configured power wheelchairs that require payment under capped rental rules provided where the provider of durable medical equipment, medical supplies, prefabricated off-the-shelf orthotics, or related items and services under 7 AAC 120.200(a)(2) requests direct purchase; and(16) items that are medically necessary to be replaced before the qualified replacement time, even if they had not initially been identified as requiring service authorization.(c) A request for service authorization must be consistent with Medicare requirements where applicable and must also include (1) a prescription order with a certificate of medical necessity completed by the enrolled ordering (B) physician assistant; or(C) advanced practice registered nurse;(2) if the recipient is under 21 years of age, documentation by the person under (1) of this subsection that the item or service is necessary to treat, correct, or ameliorate a defect, condition, or physical or mental illness; the documentation may replace the certificate of medical necessity required under (1) of this subsection(3) for requests under (b)(2) and (4) of this section relating to a request for incontinence supplies, the certificate of medical necessity required under (1) of this subsection, on a form provided by the department, that includes the (A) diagnosis, including the diagnosis code from the International Classification of Disease, adopted by reference in 7 AAC 160.900, that is related to the cause or is causing the incontinence of the bladder, bowels, or both;(B) diagnosis, including the diagnosis code from theInternational Classification of Disease, adopted by reference in 7 AAC 160.900, of the type of incontinence;(C) for recipients at least three years of age and under 10 years of age, documentation that the recipient has not responded to, would not benefit from, or has failed bowel or bladder training;(D) prognosis for controlling incontinence;(E) name of each item to be dispensed;(F) frequency of incontinence;(H) diuretic or other medications that increase output;(I) products currently being used;(J) skin integrity, including vulnerability to skin breakdown; (K) measurements of product sizes;(L) quantity of each item medically necessary;(M) known allergies to product materials; and (N) description of ability to manage incontinence independently or with assistance.(d) In addition to the requirements of (c) of this section, a service authorization request for the following items must, if available, include the manufacturer information, item description or number, global trade item number (GTIN), suggested list price, and serial number: (1) items that are identified as miscellaneous in the Healthcare Common Procedure Coding System (HCPCS), adopted by reference in 7 AAC 160.900;(2) customized or optimally configured durable medical equipment; and(3) items listed in (c)(3) of this section; a service authorization request for those items must also include the product code and national drug code (NDC), when applicable. Eff. 2/1/2010, Register 193; am 6/2/2019, Register 230, May 2019 The certificate of medical necessity form referred to in 7 AAC 120.210(a) and (c) may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167.
The United States Food and Drug Administration, Center for Drug Evaluation and Research's national drug code directory referred to in 7 AAC 120.210(d) is available at the following Internet address: https://www.fda.gov/Drugs/lnforinationOnDrugs/ucml42438.htin
The department's Alaska Medicaid DMEPOS Interim Fee Schedule, referenced in 7 AAC 145.210(b), may be obtained from the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Building L, Anchorage, Alaska 99503-7167, or at http://www.medicaidalaska.com/providers/FeeSchedule.asp.
Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040